Job Description

JOB SUMMARY: The Quality Coordinator has primary responsibility for coordination of all Medical Staff Performance Review Committees. He/she will participate in meetings providing expertise and advice to meeting participants on matters relating to regulatory compliance, medical staff bylaws, rules and regulations, core measures and SCIP, patient outcome studies, hospital processes, trended information, etc. In addition, he/she will act as liaison between committees and departments and work on medical staff teams to improve patient outcomes.

Shift: Monday- Friday

PRINCIPAL DUTIES AND RESPONSIBILITIES:

1. Consistently supports the hospital's Mission, Vision and Values of St. Joseph Medical Center (SJMC).
2. Follows the SJMC Guidelines related to the Health Insurance Portability and Accountability Act (HIPAA), designed to prevent or detect unauthorized disclosure of Protected Health Information (PHI).
3. Promotes a culture of safety for patients and associates through performance improvement activities designed to improve patient outcomes and processes throughout the Hospital.
4. Facilitates all assigned medical staff committees or other committees providing PI expertise and education related to core measure, SCIP, regulatory compliance, medical staff bylaws, rules and regulations, patient outcome studies, hospital processes, trended information, etc.
5. Demonstrates an ability to plan, organize and appropriately use resources.
6. Establishes processes to guarantee the timely completion of all committee minutes, reports and projects to assure SJMC is in full compliance with all regulatory compliance.
7. Demonstrates the ability to address issues and activities that encompass the larger aspect of operations including the ability to communicate with associates at all levels, the medical staff and external customers to meet established goals. Maintains an effective channel for productive and interactive communication.
8. Summarizes findings for the Chair of the committee making recommendations regarding findings and cases requiring medical staff review.
9. Facilitates follow up tasks to appropriate departments/committees and associates in a timely manner to ensure effective flow of information and education.
10. Responds to requests for information from other hospital departments, administration, the medical staff and outside facilities of a routine or detailed nature, as needed.
11. Independently performs special PI and outcome studies providing statistical analysis of information, identification of trends and possible patient outcome improvements.
12. Maintains knowledge of database applications providing and analyzing statistical data to be used to support PI and medical staff activities.
13. Provides for integration of PI and peer review findings with the reappointment process of the Medical Staff.
14. Supportive of the compliance program set forth by SJMC and demonstrated by:

a. Upholds the Code of Ethics and Corporate Compliance.

b. Adheres to and helps to enforce all compliance policies relevant to his/her area.

c. Assures timely compliance education as requested by the Compliance Officer and/or through corporate initiatives.

1. Sets an example to all staff in their daily activities.

MINIMUM KNOWLEDGE, SKILLS AND ABILITIES REQUIRED:

Work Experience: Work requires a professional knowledge of performance improvement functions, patient care practices, database literacy and statistical analysis techniques.

License/Registration/Certification: Licensed as a Registered Nurse in the State of Texas. CPHQ preferred.

Education & Training: Registered Nursing degree (ADN or higher)

Skills: Demonstrated ability to:

· Plan, schedule, develop task/timelines

· Read and comprehend clinical information, complex standards and regulations

· Lead work groups, communicate orally in small and large groups and in written formats

· Manage and define processes and projects to achieve identified goals within specified timelines

· Manage records and file documentation both hard and electronic

· Problem solving abilities

· Understand hospital and health system organizations and operations

· Work autonomously and as part of a medical staff team

· Maintain interests of the hospital while maintaining the confidence, respect and trust of the medical staff

· Ability to integrate and interpret data from diverse sources addressing issues of high complexity

· Ability to develop working relationships with customers (i.e. medical staff, leaders, associates).

Houston's oldest hospital is GROWING!

Welcome to St. Joseph Medical Center (SJMC), Houston's first and only downtown hospital delivering world-class care for the last 137 years and looking forward to the next century of exceptional care to Houstonians when they need us most.

Whether it's for a scheduled surgery, the birth of a baby, an unexpected emergency, or an outpatient visit, we have staff available around the clock to provide you access to immediate, quality health care. SJMC has been providing health care services to Greater Houston residents for over 130 years, which should give you great comfort in knowing that we have a great tradition of caring for our community. We strive to meet our patients' expectations and encourage our patients to provide us with feedback on how we can help them have the best experience possible while they're in our care.

Over the last years we have expanded our services to include the Advanced Wound Care Center, Comprehensive Cardiac and Vascular Services, the Women's Center, the St. Joseph Maternal Fetal Medicine Center, and a Weight Loss Surgery Program, just to name a few. As you work with our physicians, nurses, case managers, educators, and other staff, you will be guided through your health care journey, from diagnosis to treatment, with compassion every step of the way.

Diversity, equity, inclusion, and belonging are at the foundation of the care St Joseph Medical Center provides to our community we are privileged to support in all of our employment practices. We do not discriminate on the grounds of race, color, religion, sex, national origin, age, disability, veteran status, sexual orientation, gender identity, or expression or any other non-job-related characteristic.